Project Background/Rationale: Assuring patient safety in hospitals, and preventing the estimated million or more injuries that result from poor safety practices, is a top priority in our nation's health care system. Nurses and nursing processes for patient care are central to preventing adverse events and promoting patient safety in the hospital environment, yet have received comparatively little attention from patient safety researchers. Pressure ulcer prevention is a critical patient safety concern for which delivery of recommended care processes are substantially, independently shaped by nursing leadership, nursing units, and the individual nurses within the units. Nationally accepted guidelines specify nursing care processes for pressure ulcer prevention (e.g., risk assessments), yet evidence indicates low rates of nurse adherence. Care improvement requires interventions aimed at organizational change. Review of the literature on pressure ulcer quality improvement interventions directed at nurses reveals the need to understand the influence that hospital and nursing unit organizational features exert on pressure ulcer prevention. Objectives: To address this gap, we propose to conduct semi-structured interviews with nurse executives, nursing unit managers, and frontline registered nurses in six diverse VA hospitals. Our aims are to: Aim 1: Understand the relationships between organizational context and guideline-concordant pressure ulcer preventive care by: (Aim 1.1) describing variations in pressure ulcer preventive care (e.g., use of risk assessments) and their determinants within individual hospitals and units, and; (Aim 1.2) evaluating variations in pressure ulcer preventive care in relationship to organizational features: (a) nursing unit contextual features (e.g., teamwork, support services); (b) hospital contextual features (e.g., teaching status), and (c) barriers and facilitators to achieving pressure ulcer guideline concordance. Aim 2: Use our findings as the basis for an expert panel designed to inform future intervention design by assessing the importance and feasibility of different intervention strategies in the different contexts identified in the study. Methods: A team consisting of 2 researchers will conduct site visits to 6 medical units representing organizationally diverse VA hospitals. Semi-structured interviews of nursing leaders, nurse managers, and frontline nursing staff will be conducted. Interviews will focus on how hospital and unit features influence key pressure ulcer prevention processes as described in nationally-accepted guidelines. We will use Atlas.ti to perform content analysis of these data. Key findings, including organizational features perceived to promote or inhibit pressure ulcer prevention, will be presented to the study Advisory Board, with the goal of achieving consensus regarding the most important areas for future research. Brief Description of Proposal (Primary Reviewer only): Pressure ulcers are an expensive condition that impact mortality and morbidity. While there are guidelines for pressure ulcer prevention, evidence suggests that nurses are not adhering to the guidelines. The overall goal of this study is to examine the association between hospital and nursing unit organizational factors and pressure ulcer intervention. Specific aims include (1) To understand the relationships between organizational context and guideline-concordant pressure ulcer preventive care and (2) Convene an expert panel to inform future intervention efforts. The proposed study includes six sites, where the investigators will conduct site visits and semi-structured interviews with nursing leaders, management, and front-line staff. The data will be analyzed using content analysis. The findings will be presented to an expert panel during a meeting where a modified dephi process will be employed to achieve consensus regarding research priorities. Review Criteria 1. Importance of the Problem Addressed. Strengths: * Pressure ulcers are a costly problem and result in increased mortality and morbidity. Inpatient pressure ulcers are usually preventable and developing strategies to decrease ulcers could increase quality of life and result in substantial cost savings. Weaknesses: * The proposal still does not include data about the incidence of pressure ulcers in acute medical units. There is one additional citation, but it includes LTC and SCI units. The VANOD data includes data for each facility organized by bed section (acute, long term, SCI). The investigators state that this data is not published or validated, but it is possible to obtain permission to use VSSC data for research and in research proposals. While this data may not have been validated by researchers, it should provide a reasonable approximation of the magnitude of the problem. 2. Contribution to VHA. Strengths: * Understanding the relationship between nursing unit characteristics and the provision of guideline-concordant care could decrease pressure ulcer incidence and inform other quality-improvement initiatives. Weaknesses: * The barriers that are identified could lead to novel interventions, but as noted in the last review the proposed work might be necessary to developing an intervention, but it will take a few years and additional studies before an intervention can even be tested. 3. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. Strengths: * The investigators made a number of substantial changes in the proposal to address the previous comments, including a new conceptual framework and additional methodological changes that strengthen the proposal. Weaknesses: * There is still limited information about the magnitude of HA pressure ulcers in acute settings in VHA, and if the proposed research will ultimately lead to an intervention that is successful. 4. Methods. Strengths: * The sampling of the interview participants, recruitment and statistical analyses sections are well written and detailed. Weaknesses: * The revised proposal includes additional discussion about how complexity scores might be related to organizational factors that affect pressure ulcers, but the investigators do not provide a compelling argument about why the complexity factors would be better than VANOD data for choosing sites. The response memo indicates that we anticipate capturing sites with varying levels of pressure ulcer incidence and briefly mentions that VANOD data will be captured if possible, but no details are provided about how the investigators will proceed if there isn't much variation between sites or if there doesn't appear to be an association between complexity level and pressure ulcer incidence. 5. Adequacy of Data. Strengths: * The data collection plan is carefully designed and clearly explained; additional details were added to address some of the reviewers' concerns. Weaknesses: * In response to the VANOD data VANOD currently collects data about skin assessment and pressure ulcers, and these data are available through VSSC reports. These reports include information about skin assessments, daily inspections, and the number of pressure ulcers acquired during inpatient stays at VA facilities. This data could inform site selection, the construction of survey questions, and ultimately the development of the conceptual model from the expert panel, but is only mentioned as part of a future study. If there are reasons why these data would not inform the proposed research, they should be clearly addressed in the proposal. 6. Project Organization and Management. Overall, the project organization plan is detailed and appears to be appropriate. 7. Investigator Qualifications. The team is well-qualified. 8. Human Subjects. The discussion of human subjects was comprehensive. 9. Inclusion of Women and Minorities. No concerns. 10. Facilities and Resources. Excellent; there are extensive resources available through the COE. 11. Budget. Properly designed qualitative studies are expensive, and the investigators did a good job of justifying the budget. 12. Overall Strengths. * The investigative team and expert panel are very qualified and the mentoring plan is detailed * The proposal is well-written * The qualitative methods are described in detail 13. Overall Weaknesses. * Lack of background data addressing pressure ulcer incidence in VA medical units - the cited IG report is not specific to acute care units, and this data is available from VANOD. * VANOD includes a number of pressure ulcer measures that could inform the design of the study * It is still unclear if the quality improvement programs based on the proposed and future studies will decrease pressure ulcers Key Issues (Summary Points): 1. VANOD was not created for research, but many VA databases created for clinical purposes are used in studies especially when other data are not available. 2. As noted in the last review, the sampling and analyses plans are detailed and well-designed and the investigative team has excellent qualifications. 3. This is an important topic and the proposed research could eventually decrease pressure ulcer incidence in acute units, which would improve patient outcomes and decrease costs.